Healthcare Provider Details

I. General information

NPI: 1225684111
Provider Name (Legal Business Name): MORIAH PERRY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 MALCOM RD
CLINTON MD
20735-2073
US

IV. Provider business mailing address

5803 BUTTERFIELD DR
CLINTON MD
20735-2280
US

V. Phone/Fax

Practice location:
  • Phone: 301-856-0050
  • Fax:
Mailing address:
  • Phone: 240-299-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000774
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: